Cardiac transplantation, also called heart transplantation, has evolved into the treatment of choice for many people with severe heart failure (HF) who have severe symptoms despite maximum medical therapy. Survival among cardiac transplant recipients has improved as a result of improvements in treatments that suppress the immune system and prevent infection.
A heart transplant, or a cardiac transplantation, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease
The general indications for cardiac transplantation include deteriorating cardiac function and a prognosis of less than 1 year to live. Specific indications include the following:
Congenital heart disease for which no conventional therapy exists or for which conventional therapy has failed
Ejection fraction less than 20%
Intractable angina or malignant cardiac arrhythmias for which conventional therapy has been exhausted
Pulmonary vascular resistance of less than 2 Wood units
Age younger than 65 years
Ability to comply with medical follow-up care
Some patients are less suitable for a heart transplant, especially if they suffer from other circulatory conditions related to the heart. The following conditions in a patient increase the chances of complications:
Kidney, lung, or liver disease
Insulin-dependent diabetes with other organ dysfunction
Life-threatening diseases unrelated to heart failure
Vascular disease of the neck and leg arteries.
High pulmonary vascular resistance
Age over 65 years (some variation between centers)
Active systemic infection
Active systemic disease such as collagen-vascular disease or sickle cell disease
Active malignancy – Patients with malignancies who have demonstrated a 3- to 5-year disease-free interval may be considered, depending on the tumor type and the evaluating program
An ongoing history of substance abuse (eg, alcohol, drugs, or tobacco)
Inability to comply with medical follow-up care.
A typical heart transplantation begins when a suitable donor heart is identified. The heart comes from a recently deceased or brain dead donor, also called a beating heart cadaver. The patient is contacted by a nurse coordinator and instructed to come to the hospital for evaluation and pre-surgical medication. At the same time, the heart is removed from the donor and inspected by a team of surgeons to see if it is in suitable condition.
Evaluation of the heart transplant candidate includes laboratory tests, imaging studies, and other tests as appropriate.
Closely monitor the heart transplant candidate for signs of clinical deterioration during the waiting period for a suitable donor organ. Administer standard therapy for congestive heart failure (CHF), Maintain close contact with the transplant center, keeping the consultants informed of ongoing medical and social issues pertaining to the candidate.
In the event of clinical deterioration, the transplant center may deem it appropriate to admit the patient so that he or she can be evaluated for implantation of an artificial cardiac assist device, an upgrade on the waiting list, or both. At times, the candidate may deteriorate to the point where transplantation is no longer an option. Carefully discuss these issues with the treating physicians, the patient, and the family.
A hepatitis panel can serve as a screen, provided that no active antigenicity exists. Patients who are carriers of the disease or who have active disease are not considered candidates for heart transplantation. Hepatitis C positivity remains controversial with respect to thoracic transplantation and is addressed on a center-to-center basis. A large multicenter cohort study found that pre transplant hepatitis C positivity was associated with decreased survival at a mean follow-up of 5.6 years after transplantation.
The patient must not be infected with HIV. HIV positivity remains a contraindication to transplantation.
Testing for other viruses, including Epstein-Barr virus (EBV), cytomegalovirus (CMV), and herpes simplex virus (HSV), is used to determine past exposure and currently active disease. Past exposure indicates a risk of reactivation; appropriate prophylaxis should be instituted after the procedure. Treat active disease before considering transplantation. Recipients whose test results are negative for CMV are generally given CMV immune globulin. Immunize patients whose test results are negative for other viral agents during the evaluation period.
Perform fungal serologic testing and tuberculosis (TB) skin testing, paying particular attention to environmental exposure. These studies are used to determine past exposure and to predict reactivation. Patients with positive TB skin test results are usually treated before being placed on the transplantation list.
If the prostate-specific antigen (PSA) study results are positive, initiate appropriate evaluation and therapy before completing the evaluation for transplantation.
Papanicolaou test results should be negative before listing for transplantation. If the results are positive, undertake appropriate referral for evaluation and therapy before proceeding with the evaluation for transplantation.
Perform a complete blood count (CBC) with differential, platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and complete chemistry profile (including liver panel, lipid profile, and urinalysis). Results of these tests should be essentially normal. Any abnormalities must be assessed before proceeding with the evaluation.
Blood typing and screening, panel-reactive antibody (PRA) testing, and tissue typing are used to determine the immunologic suitability of the patient for transplantation and donor matching.
In the case of cardiomyopathy, coronary arteriography is performed to determine if the cause of the cardiac dysfunction may be amenable to conventional therapies such as coronary artery angioplasty, coronary artery bypass grafting (CABG), or valvular repair.
Echocardiography is used to determine the cardiac ejection fraction and to monitor the cardiac function of patients on the transplantation waiting list. Ejection fractions of 25% or less are indicative of poor long-term survival rates.
Posteroanterior and lateral chest radiographs are used to screen for other thoracic pathologies that may preclude transplantation.
Bilateral mammograms should reveal no abnormalities before listing for transplantation. If abnormalities are found, undertake appropriate referral for evaluation and therapy before proceeding further with the evaluation for transplantation.
Cardiac and Pulmonary Evaluation
Pulmonary function tests are performed to assess overall pulmonary function. Severe untreatable pulmonary disease is a contraindication to the procedure.
Maximal venous oxygen consumption (MVO2) is used to assess overall cardiac function and is used as a predictor of the severity of congestive heart failure and survival. An MVO2 value of less than 15 ml/dl/min is a poor prognostic indicator for 1-year survival in the patient awaiting cardiac transplantation.
Cardiopulmonary evaluation includes right- and left-heart catheterization to determine if the disease process is reversible or treatable by more conventional therapy. Careful evaluation of pulmonary vascular resistance is essential. Patients with fixed resistances above 4 Wood units are not candidates for the procedure.
Endomyocardial biopsy of the potential candidate is not routinely performed. The procedure may be considered if a systemic process involving the heart is thought to be the cause of the cardiomyopathy.
Perform biopsies of appropriate areas if the patient exhibits symptoms of systemic disease. Biopsies are used to determine the extent and activity of the disease process. Systemic disease processes are a contraindication to cardiac transplantation.
Monitoring and Follow-up
After transplantation, endomyocardial biopsies are performed to assess for allograft rejection. These may be performed as frequently as every week for the first month, with the frequency decreasing over time. Follow-up visits are frequent for the first month because regulation of immunosuppression is being adjusted during this time. The frequency of visits gradually diminishes until the patient is generally seen on an annual basis.
Certain centers perform coronary angiography annually after transplantation to monitor the patient for the development of allograft vascular disease.
The applicability of cardiac transplantation is limited by the availability of suitable donors. All potential donors have succumbed to brain death secondary to some catastrophic event. The underlying pathology of the donor, including cardiac contusion, cocaine use, cardiac pathology, or social history, often precludes donation. Because of the short preservation time tolerated by the heart (4-6 hours), procurement distances are limited.
Potential heart donors must meet brain death criteria and be free of cardiac pathology. Echocardiographic examination remains the best initial screening mechanism for potential donors. A normal ejection fraction (>50%) with normal valvular structure and function and an absence of left ventricular hypertrophy (as determined by echocardiography) are indicators of an excellent heart for transplantation.
Minimal abnormalities on echocardiography (eg, trivial tricuspid or mitral regurgitation, marginal left ventricular hypertrophy, or reduced ejection fraction) may also be indicators of an acceptable organ, depending on the history of the donor and the condition of the recipient. In instances where the recipient is in extremis, a less-than-ideal donor heart may be accepted in order to save the patient’s life. Donors who have a significant smoking history must be screened for coronary artery disease (CAD) with cardiac catheterization.
Current donor criteria include age younger than 65 years (though the association between heart transplant survival and donor age may not be a strictly linear one), normal cardiac function, and absence of CAD. Once these criteria are met, donor and potential recipients are matched according to blood group (ABO) compatibility and size.
The final decision regarding the suitability of the donor heart can be made only on the basis of direct inspection by an experienced surgeon. A median sternotomy incision is performed to allow inspection of the heart. Care is taken to assess the organ for potential contusions and overall function. The heart is flushed with cold cardioplegia solution, removed, and placed into cold sterile electrolyte solution for transport.
The recipient operation is performed by using cardiopulmonary bypass. The recipient heart is removed, and the donor heart is inserted in its place. The left atrial anastomosis is performed, followed by the right atrium and the great vessels.
Transplantation of Heart
While preparing a graft for transplantation, the authors look for a patent foramen ovale. If a patent foramen is present, it is closed. Many centers now perform tricuspid valve annuloplasty on donor grafts as prophylaxis against development of tricuspid regurgitation in the postoperative period.The incidence of tricuspid regurgitation after heart transplantation is reported to be as high as 47-98%.
During the cardiac transplantation procedure, the ventricles are excised, leaving the great vessels, right atrium, and left atrium of the recipient . The donor heart is then sewn to these areas .
A cardiac allograft can be sewn in either a heterotopic or an orthotopic position. The authors rarely perform heterotopic heart transplants because of the inherent problems (eg, pulmonary compression of the recipient, difficulty obtaining endomyocardial biopsy, need for anticoagulation); however, heterotopic transplantation is an excellent technique for patients with severe pulmonary hypertension.
Orthotopic heart transplantation is performed either with the classic Shumway-Lower technique or as a bicaval anastomosis . Currently, there is a trend toward reverting to bicaval anastomoses rather than right atrial anastomoses in an attempt to decrease the incidence of postoperative tricuspid insufficiency.
The Shumway-Lower method is simpler and saves perhaps 10-15 minutes of ischemic time. One advantage of the bicaval method is that, by avoiding a large right atrium, the surgeon can maintain better atrial transport. Another claimed advantage of this technique is a lower reported incidence of tricuspid regurgitation.
An additional advantage of the bicaval technique is that when the ischemic time of the allograft is too long because of transportation or surgical extraction of the recipient heart/ventricular assist device, the donor heart can be better preserved by continuous cold retrograde blood cardioplegia through the coronary sinus. Of course, topical cooling of the graft continues to be the primary means of graft preservation.
After the procedure, the patient is maintained on a combination of pressor agents while the donor heart regains energy stores. The patient’s ionized calcium level is carefully monitored and replaced with calcium chloride because the function of the denervated heart initially is extremely dependent on circulating calcium ions. The acid-base status of the patient is also carefully monitored and corrected.
Immunosuppression is started soon after surgery. Several regimens can be used, including pre transplantation induction therapy and simple postoperative maintenance therapy; the choice of regimen depends on the training and experience of the transplant center.
Once stabilized, the patient is rapidly weaned from the ventilator and the pressors. The post-transplant hospital stay can be as short as 5 days, depending on the condition of the recipient before the operation.
In the transplantation process, the sinoatrial nodes of the donor and recipient remain intact, and both are present within the recipient. For approximately 3 weeks after surgery, electrocardiography (ECG) demonstrates 2 P waves; however, the heart rate and electrical activity of the new heart are purely dependent on the intrinsic electrical system of the heart, not on the neurologic input from the recipient.
Once the donor heart passes inspection, the patient is taken into the operating room and given a general anaesthetic. Either an orthotopic or a heterotopic procedure follows, depending on the conditions of the patient and the donor heart.
The orthotopic procedure begins with a median sternotomy, opening the chest and exposing the mediastinum. The pericardium is opened, the great vessels are dissected and the patient is attached to cardiopulmonary bypass. The donor’s heart is injected with potassium chloride (KCl). Potassium chloride stops the heartbeat before the heart is removed from the donor’s body and packed in ice. Ice can usually keep the heart usable four to six hours depending on preservation and starting condition. The failing heart is removed by transecting the great vessels and a portion of the left atrium. The patient’s pulmonary veins are not transected; rather a circular portion of the left atrium containing the pulmonary veins is left in place. The donor heart is trimmed to fit onto the patient’s remaining left atrium and the great vessels are sutured in place. The new heart is restarted, the patient is weaned from cardiopulmonary bypass and the chest cavity is closed.
In the heterotopic procedure, the patient’s own heart is not removed. The new heart is positioned so that the chambers and blood vessels of both hearts can be connected to form what is effectively a ‘double heart’. The procedure can give the patient’s original heart a chance to recover, and if the donor’s heart fails (e.g., through rejection), it can later be removed, leaving the patient’s original heart. Heterotopic procedures are used only in cases where the donor heart is not strong enough to function by itself (because either the patient’s body is considerably larger than the donor’s, the donor’s heart is itself weak, or the patient suffers from pulmonary hypertension).
‘Living organ’ transplant
In February 2006, at the Bad Oeynhausen Clinic for Thorax and Cardiovascular Surgery, Germany, surgeons successfully transplanted a ‘beating heart’ into a patient. Rather than cooling the heart, the living organ procedure keeps it at body temperature and connects it to a special machine called an Organ Care System that allows it to continue pumping warm, oxygenated blood. This technique can maintain the heart in a suitable condition for much longer than the traditional method.
The patient is taken to the ICU to recover. When they wake up, they move to a special recovery unit for rehabilitation. The duration of in-hospital, post-transplant care depends on the patient’s general health, how well the heart is working, and the patient’s ability to look after the new heart. Doctors typically prefer that patients leave the hospital 1 – 2 weeks after surgery, because of the risk of infection and presuming no complications. After release, the patient returns for regular check-ups and rehabilitation. They may also require emotional support. The frequency of hospital visits decreases as the patient adjusts to the transplant. The patient remains on immunosuppressant medication to avoid the possibility of rejection. Since the vagus nerve is severed during the operation, the new heart beats at around 100 beats per minute unless nerve regrowth occurs.
Immunosuppressive agents are continued in the intensive care unit.
The patient is regularly monitored to detect rejection. This surveillance can be performed via frequent biopsy or a gene expression blood test known as AlloMap Molecular Expression Testing. Typically, biopsy is performed immediately post-transplant and then AlloMap replaces it once the patient is stable. The transition from biopsy to AlloMap can occur as soon as 55 days after the transplant.
The goals of pharmacotherapy are to prevent complications, to reduce morbidity, and to reduce the chances for organ rejection.
Immunosuppression is started soon after surgery. Transplant recipients are maintained on an immunosuppression regimen that includes 1-3 drugs. Generally, the drugs fall into 3 categories: steroids, antimetabolites, and other immunosuppressants. Several regimens can be used, including pre transplantation induction therapy and simple postoperative maintenance therapy; the choice of regimen depends on the training and experience of the transplantation center.
Cyclosporine (Neoral, Sandimmune, GENGRAF)
Cyclosporine is a cyclic polypeptide that suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions such as delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, and graft versus host disease for various organs.
For children and adults, base dosing on ideal body weight. Maintaining appropriate levels of the drug in the bloodstream is crucial to the maintenance of the allograft. Foods can alter the level of the drug and time of administration. Medication must be taken at the same time every day.
Neoral is the capsular form of cyclosporine, available in 25- and 100-mg capsules. Sandimmune is the liquid form. GENGRAF is the branded generic form, available in 25- and 100-mg capsules.
Prednisone is an immunosuppressant used for the treatment of autoimmune disorders. It may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear (PMN) leukocyte activity. It is an oral steroid with approximately 5 times the potency of endogenous steroids. Minimal to no oral prednisone should be given for the first 21 days after transplantation unless rejection occurs.
Methylprednisolone (Medrol, Solu-Medrol, A-Methapred)
Methylprednisolone is an immunosuppressant used to treat autoimmune disorders. It may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. It is the intravenous (IV) form of prednisone.
Tacrolimus suppresses humoral immunity (T-cell activity). It is a calcineurin inhibitor with 2-3 times the potency of cyclosporine. Tacrolimus can be used at lower doses than cyclosporine, but it has severe adverse effects, including renal dysfunction, diabetes, and pancreatitis. Levels are adjusted according to renal function, hepatic function, and adverse effects.
Mycophenolate mofetil (CellCept, Myfortic)
Mycophenolate mofetil inhibits inosine monophosphate dehydrogenase (IMPDH) and suppresses de novo purine synthesis by lymphocytes, thus inhibiting their proliferation. It inhibits antibody production.
Azathioprine (Imuran, Azasan)
Azathioprine antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteins. It may decrease proliferation of immune cells, which results in lower autoimmune activity. Antimetabolites are used to block the uptake of vital nutrients needed by the cells. As implied, these drugs affect not only the cells of the immune system but also other cells of the body. The potency of therapy is dose dependent. Azathioprine is not effective treatment for acute rejection episodes but remains an economical choice for long-term immunosuppression.
Sirolimus, also known as rapamycin, is a macrocyclic lactone produced by Streptomyces hygroscopicus. It is a potent immunosuppressant that inhibits T-cell activation and proliferation by a mechanism that is distinct from those of all other immunosuppressants. This inhibition suppresses cytokine-driven T-cell proliferation by inhibiting progression from the G1 phase to the S phase in the cell cycle.
After the procedure, the patient is maintained on a combination of pressor agents while the donor heart regains energy stores. Once stabilized, the patient is rapidly weaned from the ventilator and the pressors. The chosen combination depends on the training and experience of the center.
Dopamine is a naturally occurring endogenous catecholamine that stimulates beta1-and alpha1-adrenergic and dopaminergic receptors in a dose-dependent fashion. It stimulates the release of norepinephrine.
In low doses (2-5 μg/kg/min), dopamine acts on dopaminergic receptors in renal and splanchnic vascular beds, causing vasodilatation in these beds. In midrange doses (5-15 μg/kg/min), it acts on beta-adrenergic receptors to increase heart rate and contractility. In high doses (15-20 μg/kg/min), it acts on alpha-adrenergic receptors to increase systemic vascular resistance and raise blood pressure.
Dobutamine is a sympathomimetic amine with stronger beta than alpha effects. It increases the inotropic state. Vasopressors augment the coronary and
cerebral blood flow during the low-flow state associated with severe hypotension.
Dopamine and dobutamine are the drugs of choice to improve cardiac contractility, with dopamine the preferred agent in hypotensive patients. Higher dosages may cause an increase in heart rate, exacerbating myocardial ischemia.
Its alpha-agonist effects include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. Its beta2-agonist effects include bronchodilation, chronotropic cardiac activity, and positive inotropic effects.
Norepinephrine stimulates beta1- and alpha-adrenergic receptors, increasing cardiac muscle contractility and heart rate, as well as vasoconstriction; this results in systemic blood pressure and coronary blood flow increases. After obtaining a response, the rate of flow should be adjusted and maintained at a low-normal blood pressure, such as 80-100 mm Hg systolic, sufficient to perfuse vital organs.
Post-operative complications include infection, sepsis, organ rejection, as well as the side-effects of the immunosuppressive medication. Since the transplanted heart originates from another organism, the recipient’s immune system typically attempts to reject it. The risk of rejection never fully goes away, and the patient will be on immunosuppressive drugs for the rest of his or her life, but these may cause unwanted side effects, such as increased likelihood of infections, like fevers, unusual pains, or any new feelings. Recipients can get kidney disease from a heart transplant. Many recent advances in reducing complications due to tissue rejection stem from mouse heart transplant procedures.
Complications after transplantation include bleeding from the suture lines. This is a rare occurrence but may require reexploration in the early postoperative period.
Hyperacute rejection can occur immediately after blood flow is restored to the allograft and up to 1 week after the procedure, despite therapeutic immunosuppression. Bridging with mechanical assistance may be advantageous in acute allograft rejection.
Infection is the primary concern in transplant patients. Preventive measures should be instituted. During the early posttransplant course, bacterial infections are of primary concern. Fungal infections can appear if the patient is diabetic or excessively immunosuppressed. Prophylaxis for Pneumocystis carinii is universally administered, as is therapy for cytomegalovirus (CMV) infection. Maintain vigilance for other uncommon infectious processes, including Listeria, Legionella, Chlamydia, and Nocardia infection.
Psychiatric disturbances from steroid therapy can occur in the immediate posttransplant period. These disturbances may be predicted from the pretransplant psychiatric evaluation and thus averted.
Cardiac rejection is to be expected and should be detected by endomyocardial biopsy.Depending on the severity of the incident, the process can be treated with steroid therapy alone, polyclonal antibody therapy, or monoclonal antibody therapy.
Allograft vascular disease is the main cause of late graft failure and death. A progressive concentric myointimal hyperplasia develops in the coronary arteries, sometimes as early as 3 months after transplantation. The cause of the process is unclear. However, CMV infection and recurrent rejection episodes are thought to be associated with the cause. Research suggests that the initial ischemia-reperfusion injury, coupled with repeated rejection episodes, might contribute to the process.
The only therapy available for allograft vascular disease is retransplantation. The process can sometimes be treated by stenting the diseased vessels. Drug-eluting stents appear to be more effective in treating cardiac allograft vasculopathy than bare-metal stents are. Drug-eluting stents reduce target lesion revascularization, as well as rates of cardiac death and nonfatal myocardial infarction.
In pediatric patients, there is a 30% increase in the risk of graft loss within 6 months when the ischemic time is longer than 3.5 hours.
Care of the heart transplant patient
In the immediate postoperative period – until haemostasis and haemodynamic stability are achieved – the patient will be nursed in a designated cardiac ICU. Extubation is usually rapid, and done once arterial blood gases are found to be satisfactory. Management of the patient usually includes monitoring intra-arterial blood pressure, central venous pressure (CVP), left atrial pressure (LAP) and pulmonary artery pressures (PAP).
Intravenous infusions may include inotropic support, fluid and volume replacement, anti-rejection therapy and analgesia. Mediastinal drains and a urinary catheter will also be in situ.
A prolonged stay in ICU may be necessary if the patient has complications such as bleeding, right-sided cardiac dysfunction or bi-ventricular failure requiring multiple inotrope therapy, an intra-aortic balloon pump or ventricular-assist device.
Patients will be transferred to the transplant unit when extubated six to 24 hours after surgery, where they will usually remain until discharge
Following transfer, ECG monitoring and routine observations will be sustained. In addition, invasive blood pressure and CVP monitoring will continue for a day or two. Mediastinal drains are usually removed soon after transfer when drainage is minimal.
Maintenance of a heart rate of 100-110bpm is an important aspect of early postoperative care that enables optimal cardiac output and adequate renal perfusion to be achieved. In addition, reduction of pulmonary vascular resistance is beneficial for right ventricular function. Isoprenaline is administered to achieve both of these, although temporary pacing via epicardial wires may be required. Additional inotropes/vasodilators such as milrinone/adrenaline or glyceryl trinitrate may be used, depending on the patient.
If the patient’s cardiac function is satisfactory and adequate hydration is achieved, maintaining adequate blood pressure is not usually a problem in the early postoperative period. Hypertension is common following cardiac transplant; this is often drug-induced and generally caused by anti-rejection therapy: ACE inhibitors and calcium channel blockers are common treatments.
Life-threatening arrhythmias are rare postoperatively, even during acute rejection episodes. Atrial flutter/fibrillation is occasionally seen in patients and, if problematic, can be treated with overdrive atrial pacing, amiodarone or, more rarely, DC cardioversion.
Patients rarely experience respiratory problems. Intense physiotherapy, observation of respiratory rate, oxygen saturations, and regular chest X-rays will allow early identification of pulmonary atelectasis. Precise fluid management will help prevent pulmonary oedema. Oxygen therapy will be weaned as the patient’s clinical condition allows.
Fluid balance/renal function
The assessment and management of a patient’s fluid balance following heart transplant can be challenging. It is essential to keep a fluid balance record, to check the patient’s weight daily, as well as make regular checks of their urea and electrolyte levels, and do clinical examinations. Patients are often oedematous, and this is caused by a combination of fluid overload and having low albumin levels preoperatively. Diuretics are frequently used but care must be taken not to cause hypovolaemia.
Most patients will present with renal dysfunction at the time of transplant, secondary to heart failure. The insult of surgery, potential hypotensive episodes perioperatively and nephrotoxic anti-rejection therapy usually worsens renal function in the early days.
Regular monitoring of urea and electrolyte levels, maintenance of optimal fluid balance and avoidance of unnecessary nephrotoxic drugs will help. Dialysis may, occasionally, be necessary. Renal-dose dopamine is no longer used routinely for all patients, as many studies have questioned its value .
Rejection following cardiac transplant is most common in the first six to 12 weeks, although it can occur at any time. Triple therapy anti-rejection treatment consisting of cyclosporin, azathioprine and prednisolone is most commonly administered postoperatively, but the drug regimen will vary from centre to centre. Agents such as tacrolimus, and mycophenolate mofetil can also be used.
All anti-rejection therapy has side-effects that include:
Abnormal liver function;
Post-transplant lymphoproliferative disease;
Increased incidence of skin cancer/malignancies;
Acne/moon face/facial hair;
Signs and symptoms of rejection may include:
Low grade temperature;
Shortness of breath;
Soft heart sounds/S3 gallop.
Balancing the dose of anti-rejection drugs is crucial both to minimise rejection and avoid a high level of side-effects.
The most accurate way of determining rejection remains endomyocardial biopsy. This is initially carried out at weekly intervals and gradually reduced in frequency, according to individual need. Biopsy specimens are examined and graded according to the International Society of Heart and Lung Transplantation guidelines as described by Hakim (1997). Forty per cent of patients will require treatment for rejection in the first six weeks, through intravenous administration of methyl prednisolone 10mg/kg for three days.
Patients taking immunosuppressive drugs are inevitably at risk of infection. All patients are initially nursed in cubicles with restricted visiting. The focus of care to minimise infection risk is early extubation, the removal of lines and ambulation. Antibiotic therapy of flucloxacillin 500mg four times a day is given for 48 hours. In addition, short-term anti-infective treatment will include nystatin suspension (antifungal mouthwash); acyclovir 200mg three times a day (antiviral); and sulfamethoxazole trimethoprim 480mg once a day (to prevent Pneumocystis carinii infection).
Any signs and symptoms of infection including pyrexia and raised white-cell count will be investigated and, where possible, an organism identified before further antibiotics are commenced; broad-spectrum antibiotics are rarely used. Patients are taught to take their own temperature and recognise signs and symptoms of common infections.
Good pain control is essential to aid recovery from transplant and facilitate cooperation with physiotherapy. Although all patients are assessed individually, patient-controlled analgesia (morphine) is commonly used, followed by oral dihydrocodeine and paracetamol. Patients are encouraged to express their needs. Referral to the specialist pain team can be made, if necessary.
All patients are assessed for the risk of deep-vein thrombosis and will usually be prescribed low molecular weight anticoagulants once a day until they are mobile. Patients who develop thromboembolic problems may require formal anticoagulation therapy.
Mobility and independence are encouraged as the patient’s condition and confidence improve: they are encouraged to sit out of bed on day two, start walking around at four to five days postoperatively and attend the gym on day eight, following a satisfactory cardiac biopsy result. Each patient will require an individual exercise plan tailored to his or her needs.
Nutrition and hydration
As soon as adequate gastrointestinal function is established, patients are encouraged to eat and drink, and intravenous fluids are discontinued. A good fluid intake of 2L in 24 hours is optimal. In the early postoperative period, a diet high in protein and calories is encouraged to aid recovery and tissue repair.
Early dietetic input is established, as patients may require advice on low-potassium, low-sugar or high-magnesium needs. Long-term advice will recommend patients adhere to a low-saturated fat diet, to prevent obesity and raised lipid levels. Constipation will be treated with basic interventions.
Patients will usually be mobile and independent about one week postoperatively, inotropes and monitoring will normally have been discontinued, and the focus of care will shift to education and rehabilitation. It is often around this time that a patient’s emotional and psychosocial needs increase.
Postoperative psychological issues
Although successful transplantations have much to do with advances in surgical technique, physical management and immunosuppression, a patient’s emotional and behavioural responses contribute significantly to long-term survival and progress following transplantation.
The education process starts as soon as the patient is able to cope with it (three to seven days postoperatively). This is a structured programme that covers self-medication, awareness of side-effects, self-monitoring of signs and symptoms of rejection and infection, checking temperature and weight, and general health advice. Teaching is relaxed and informal and continues in the outpatient clinic.
Transplantation support is family focused; lack of carer support has been identified as a cause for non-compliance and, therefore, poor recovery. It is, however, important that the transplant recipient takes responsibility for their recovery and well-being.
Both patient and family will initially feel euphoria following a successful transplant, and may have difficulty accepting potential complications in the postoperative period . As a result, if complications occur they can be devastating, owing to a growing realisation that the patient’s lifespan is unpredictable .
The emotional and psychological trauma of transplantation cannot be underestimated. After the initial feelings of euphoria, the recipient may become depressed and irritable. It is an important aspect of the transplant nurse’s role to help the patient and family through some of the difficulties. It is important that the nurse be aware of the feelings the patient may be experiencing.
It is the policy at our centre to discuss donor details such as age/sex/cause of death. Some patients have an overwhelming need to know about their donor, others may ask years later, and some never feel the need to discuss donor issues. Patients are supported through this time. Thank-you letters can be passed to donor families via the transplant coordinators.
The stress of waiting for a transplant and coming to terms with life afterwards, including changes in life expectancy, long-term complications, and a changing of roles (from sick to well).
Partners often put their life on hold until after the transplant and take on the main role in the family. After transplant it may be difficult to give up these acquired responsibilities, which can result in conflict between the patient and their partner. Relationship problems experienced pre-transplant can often be heightened rather than resolved after the operation.
Side-effects from medication
All patients will initially be started on a regimen of high-dose steroids which in themselves can result in depression even before the occurrence of side-effects such as obesity and excessive hair growth.
Body image and compliance
Changes in body image can affect the patient’s recovery and subsequent drug compliance. Non-compliance with drug therapy/clinic attendance can result in transplant rejection, increased mortality and excessive health costs.
It is also identified adolescents as a higher risk group for non-compliance than the over-forties. Younger recipients often perceive themselves as victims, whereas older recipients are grateful for a second chance . Many adolescents have difficulty in coping with the altered body image caused by the medication.
Multidisciplinary interventions used to improve compliance and patient recovery include:
Thorough explanations of the need for medication and clinic visits (even when the patient feels well);
The planning of medication regimens to fit into the person’s lifestyle, through mutually acceptable times,
The creation of opportunities to discuss emotional issues, for example, hospital helplines;
Rehabilitation and outpatient care
Rehabilitation and education are ongoing processes following the operation, culminating in discharge into hospital accommodation or home within two to three weeks of transplantation.
Outpatient visits are frequent in the early postdischarge period, and medications, investigations and follow-up are adjusted on an individual basis. Within three months, the majority of patients will be able to lead a normal lifestyle and many consider returning to work.
In this time of surgical and medical miracles, it is important to recognise that for the well-being and long-term survival of transplant patients, the multidisciplinary input of transplant coordinators, nurses, social workers, psychologists, physiotherapists, chaplains and even ward domestics is paramount. Despite the worry and upheaval of having a transplant, the recipients see the process as worthwhile (Greaves, 1997).
Transplantation is a specialty that depends not only on the medical staff, but on the team as whole. Furthermore, none of this would be possible without the courage of the donor families and the dedication of the teams that support them.
High risk for infection related to altered immune system secondary to immunosuppressant medications
High risk for altered oral mucous membrane related to increased susceptibility to infection secondary to immunosuppression
High risk for self-concept disturbance related to transplant experience, potential for rejection, and side effects of medications
High risk for noncompliance related to complexity of treatment regimen and euphoria
High risk for ineffective management of therapeutic regimen related to insufficient knowledge of prevention of infection, activity progression, dietary management, daily record keeping, pharmacologic therapy, signs and symptoms of infection and rejection, effective birth control measures/pregnancy recommendations, follow-up care, and community resources.
Anxiety related to unconscious conflict about essential values and beliefs; situational crises, interpersonal transmission or contagion; perceived or actual threat to self-concept, organ rejection, threat of death; side effects of steroids and/or cyclosporine
Nursing Times .Net ,Care of the heart transplant patient:9 July, 2002:VOL: 98, ISSUE: 28, PAGE NO: 34
ISHLT Guidelines for the Care of Heart Transplant Recipients Long-term Care of Heart Transplant Recipients (Aug. 6, 2010).